Illinois Division of Mental Health Quality & Safety Improvement Initiative

1. Illinois Division of Mental HealthQuality & Safety Improvement Initiative Charter Team Topic: Serious Incident Management Hospital: McFarland MHC QCSI III Charter Teams Report Out Meeting June 24, 2013 – Springfield, IL DRAFT: For Review and Discussion

2. Charter Team Members • Natalie Katauski, Quality Manager (Leader) • Val Bales, Clinical Director (Facilitator) • Christine Elvidge, Recovery Specialist • Dr. Sreehari Patibandala, Psychiatrist • Dr. Renee Alonso, Physician • Sherrill Weddersten, Clinical Nurse Manager • Sheila F., Stevenson Hall • Paul Pomeroy, Training Coordinator DRAFT: For Review and Discussion

3. Overview of Deliverables • Design and develop a process that consistently and reliably manages serious incidents in a timely manner. • Design and develop training to ensure staff knowledge and appropriate/effective application and use of the serious incident management (SIM) process. • Identify a core set of activities that indicate appropriate use of the SIM process with recommendations for related evaluation measures and monitoring activities. DRAFT: For Review and Discussion

4. QCSI Charter Team Work Process • The PI Team met weekly. • Prior to the first meeting an extensive literature search was completed, the team received incident management policies and procedures from community and state operated hospitals. This information was used to develop definitions, create a Risk Level Matrix for grading incidents and determining type of review. • Once those parameters were established, the Team drafted a Program Directive and a Reporting Process Decision Tree. DRAFT: For Review and Discussion

5. Difficulties/Barriers • The Team had a significant amount of work to accomplish in a short amount of time. This project was a priority and the members committed to maintaining focus and ensuring assigned tasks were completed as scheduled. DRAFT: For Review and Discussion

6. Deliverables/Work Products • Develop a Process that manages serious incidents timely: an extensive literature search was completed, the team received incident management policies and procedures from community and state operated hospitals. This information was used to develop definitions, create a Risk Level Matrix for grading incidents and determining type of review. • Design and develop training: Training will include review of Program Directive, Risk Level Matrix and Reporting Process Decision Tree (Handouts 1, 2 & 3). Three mock scenarios will be used to evaluate appropriate use of the risk level matrix. DRAFT: For Review and Discussion

7. Deliverables/Work Products • Identify a core set of activities that indicate appropriate use of the SIM process: - Leadership staff will review security incident reports to ensure all serious incidents are reported/processed according to Directive. - A SIM Report (Handout 4) will be completed and forwarded to the Quality Coordinator at designated intervals. Report will detail the event, risk level, system failures, root causes, lessons learned, plans of correction and related status reports. This report will be discussed at identified Quality Manager meetings.

8. Outstanding Questions/Issues • There is a risk that a serious incident may not be reported properly or recognized as a critical event. DRAFT: For Review and Discussion

9. Lessons Learned/Recommendations • Consider baseline data collection (utilizing the SIM Report) for the last fiscal year and compare data collected over the next year. Determine effectiveness of SIM in reducing negative outcomes (facility specific and system wide). DRAFT: For Review and Discussion